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Table of Contents
ORIGINAL ARTICLE
Year : 1998  |  Volume : 1  |  Issue : 1  |  Page : 49-53

Tympanoplasty out come: King fahd hospital experience in Jeddah


Al Mosadia ENT Centre, King Fahad Hospital, Jeddah, Saudi Arabia

Date of Web Publication16-Jun-2020

Correspondence Address:
M.D. Abdul Monem Hassan Al-Shaikh
Al Mosadia ENT Centre, King Fahad Hospital, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.286857

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  Abstract 


Tympanoplasty is one of the commonest operations done among ENT Surgical procedures nowadays. A total of 1188 Type-I Tympanoplasty and Myringoplasty were done at TheENT Centre, King Fahad Hospital, Jeddah, during tiie period, January 1990 to December 1994 by various surgeons starting from resident to consultant. A retrospective analysis of 950 cases, which were followed up for more than 3 months was done.
The male to female ratio was 46:54 and the mean age being 23.5 years. Five Hundred three cases (53%) had subtotal perforations, 333 (35%) with large central perforations and 114 (12%) had small central perforations. All the ears were dry for at least one month preoperatively. The over all success rate was 741 cases (78%). The success rate of combined posterior-anterior flap technique was higher than the posterior flap alone. The average hearing gain was 20dB. The outcome of tympanoplasty is analysed in relation to the techniques, middle ear pathology, and reasons of failure.

Keywords: Tympanoplasty, posterior flap, posterior-anterior flap, cholesteatoma


How to cite this article:
Al-Shaikh AM, Reddy V. Tympanoplasty out come: King fahd hospital experience in Jeddah. Saudi J Otorhinolaryngol Head Neck Surg 1998;1:49-53

How to cite this URL:
Al-Shaikh AM, Reddy V. Tympanoplasty out come: King fahd hospital experience in Jeddah. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 1998 [cited 2022 Nov 30];1:49-53. Available from: https://www.sjohns.org/text.asp?1998/1/1/49/286857




  Introduction Top


Tympanic membrane repair has been performed for more than a century. In 1878 Berthold [1] successfully closed a perforation with full thickness skin and introduced the term “Myringoplastik”. Reporting similar operations by Ely, 1881 [2] and Tangemann 1884 [3] soon followed. However, enthusiasm subsequently waned. Tympanoplasty was introduced in the 1950’s with the advent of the operating microscope and with availability of antibiotics, Wullestien and Zollner [4] provided the main stimulus to the development of new tympanoplastic techniques in the reconstruction of ears damaged by otitis media.

In 1961, Storss [5] described the successful use of autograft temporalis fascia in the underlay position for closure of tympanic membrane perforations. Different materials were described for grafting, including amniotic membrane, periosteum, vein, connective tissue, perichondrium, dura. [4],[5],[6] Nowadays tympanoplasty is one of the commonest operations done in any leading hospital with the underlay technique using temporalis fascia graft being the most popular method.

Tympanoplasty in our institute is performed by consultants, specialists residents under supervision of senior staff. Post auricular, endaural and sometimes the endomeatal routes were used. Homologous temporalis fascia was used in revision cases. The results are analyzed and causes of failure are discussed.

Temporalis fascia was used in most of the of the cases, and in few cases perichondrium.

Homologous temporalis fascia was used in revision cases. The results are analysed and causes of failure are discussed.


  Patients and Methods: Top


This a retrospective review of files of 1188 ears which were operated upon at Al-Mosadia E.N.T. Centre, King Fahad Hospital, Jeddah, during the 5 years period from January 1990 to December 1994. The surgeons involved included consultants, specialists and residents under supervision of senior staff. All the ears were dry for at least one month, preoperatively. Two hundred and thirty eight cases were excluded since they were followed for less than 3 months. The 950 cases whose results were analysed had a follow up period between 3 months to 2 years. The condition of the middle ear was assessed at the time of admission and before starting surgery under the microscope. All cases underwent either Type I - Tympanoplasty or Myringoplasty. Post- auricular, endaural, and in few cases, the endomeatal approach was used. The underlay technique was the method used utilising mostly temporalis fascia as a graft material, perichondium sometimes and homologous temporalis fascia (Tutoplast®,Biodynamic International Company )in revision cases. Ears with cholesteatoma and other types of tympanoplasty were not included. All patients had pre-operative, and post- operative audiograms done. Results were analysed in relation to the size of perforation, techniques and middle ear pathology .


  Results Top


In this study the male to female ratio was 46:54. The age range was 9-69 years with a mean age of 23.5 years. Duration of discharge was less than 5 years in (23%), 5-10 years in (34%) and since childhood in (43%) of cases.

In 692 (73%) of cases the middle ear was dry and healthy and in 258 (27 %) oedematous and polypoidal, though the ear was free of discharge for more than 4 weeks. Tympanosclerosis noticed intraoperatively in 361 cases (38%) which sometimes restricted the ossicular mobility.

There were subtotal perforation in 503 (53%) ears, sometimes with absence of anterior annulus, and large central perforations in 333 (35%) of ears. The post-auricular approach was used in 589 (34%) ears and endomeatal approach in 38 (4%) depending on surgeon’s preference. Posterior meatal flap was elevated in 741(78%) ears and in 180 (19%) both posterior and anterior flaps were elevated with the underlay graft being tugged under anterior meatal skin (modified Kerr flap). Circular flaps were used in 29 (3 %) of ears. Preoperative hearing loss was mild to moderate in 722 (76 %) ears, moderate to severe in 190 (20%) with mixed element and severe to profound in 38(4%) ears.

Patients were seen after 3 weeks postoperatively, at which time the ear pack was removed, gelfoam sucked and status of graft assessed. An audiogram was done at 8 weeks. If the graft was intact at the end of two months the operation was considered as a success. Patients were then seen twice at 6 months interval if there were no complications. In bilateral cases the second ear was operated 6 months after the first operation. Five hundred and fifty one (58 %) patients were followed up for 3-6 months, in 325 (34 %) cases upto one year (usually bilateral cases), and in 74 (8 %) ears upto 2 years (usually revision cases).

The initial success rate was 741 (78 %) ears. At the end of two months, success and failure were assessed separately in relation to the size of perforation, technique, and middle ear pathology. The success rate was higher in cases where both anterior and posterior flaps were used -155 ears (86%)- when compared with posterior flap technique (563 ears (76%) )• Circular flaps were used mainly in subtotal to total perforation cases the results of which are shown in [Table 1]. The type of approach is shown in [Table 2]. The type of graft material (temporalis fascia, perichondrium, homologous graft) did not seem to affect success rate.
Table 1: Showing Type Of Flap &Success Rate

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Table 2: Showing Type Of Incision &Success Rate

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As regards the middle ear pathology the success rate dropped markedly when middle ear mucosa was oedematous and polypoidal [Table 3]. When the middle ear was completely dry and healthy the graft take was up to 81% (559 ears). Tympanosclerosis observed intraoperatively, did not affect graft success rate though in most of these cases hearing gain was not much due to restricted ossicular mobility [Table 3] & [Table 4].The success rate as related to the type of perforation is shown in [Table 5].
Table 3: Showing middle ear pathology &Success Rate

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Table 4: Showing Hearing Gain

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Table 5: Showing Type Of Perforation &Success Rate

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Few post-operative complications were noticed in our series. Infected stitches with small abscesses were treated successfully. post-operative severe infection seen in 15 patients. Twenty three patients had sensorineural hearing loss (mild to moderate) and transient dizziness occurred in 35 patients. In graft failure cases, careful history taken showed patients to have had attacks of common cold in the first 2 weeks after the operation (29 patients), some patients went for swimming [17] early after the operation and 8 patients traveled by air within 2 weeks of operation.


  Discussion Top


Numerous surgeons have reported results of myringoplasty utilising various techniques.[7],[8],[9]. Sade et al [10] published their short term and long term results of myringoplasty in a training program and he short-term success rate of 81%. Our series are on par with published results. [8],[9],[10] As compared to other authors [7], [9], [11] age, sex, type of graft and tympanosclerosis did not influence the success rate. In our series all operations were performed under general anaethesia using the underlay graft technique. In revision operations we used, tragal perichondrium or homologous temporalis fascia and there was no difference in graft take up rate. Gibb et al [12] in their review of 365 myringoplasties found no significant difference between the success rate for central or marginal perforations condition of ear(dry or wet)and presence of typanosclerosis. But they suggested that in subtotal perforations contact between the tympanic membrane and the graft may be minimal and, if the overlap is to be improved, it is essential to spread the graft over the adjacent bone and thus increase the contact area. Hordijk et al [13] in their series of 250 ear operations, studied different graft materials; temporalis fascia, perichondrium and vein graft. The graft take up rate was the same, though they found hearing gain was low when they used vein graft. Cable [14] observed that the surface tension plays a role in the maintenance of graft stability. Graft stability increases in proportions to the distance of overlap between the graft and tympanic membrane remnant and the ideal overlap varies with the size of the perforation. For perforations of 5-6 mm in diameter, a 2mm overlap is required, whereas in smaller perforations a 2-5 mm overlap is advisable.

When dealing with subtotal perforations, in our series, we made the anterior flap to overcome the failure as advised by others.[15],[16] We modified Kerr’s technique of tugging the graft anteriorly and got better results with combined posterior / anterior flaps (86 %), compared with posterior flap alone (76 %). In contrast to some authors [10],[11],[12] we found that the condition of the middle ear mucosa influented the results. The graft take rate was high if the middle ear was completely dry (81%), than when it was odematous and polypoidal (70%).

Shih et al and other others [17],[18],[19],[20] found myringoplasty in children to be quite successful. In our series the youngest was 9 years old. Usually we do not operate on children less than 10 years old, because of high incidence of upper respiratory tract infections. Gimenz and Marco Algarra [21] observed that the mucociliary clearance is a good prognostic factor in tympanoplasty. Good mucociliary clearance in the middle ear gives good results. Luetje [22] has advised to keep scored tragal cartilage as free graft in middle ear against the medial wall of middle ear, between the oval and round windows, to prevent retraction of the graft, into the sinus tympani.

Post-operative infection plays an important role in graft failure. An attack of acute upper respiratory infections in the immediate post operative period and irregular intake of antibiotics and not completing the course decreased the success rate. Hearing gain on an average, was 20-35 dB.


  Conclusion Top


  1. Tympanoplasty Type I and Myringoplasty results were not affected by age, sex duration of discharge, type of graft and kind of approach to the middle ear.
  2. There was slight difference in the success rate between small and sub total perforations. Technical failure was more frequent in subtotal perforations, leading to shifting of the graft and residual perforations.
  3. To overcome these technical failures, we used the combined posterior / anterior flap in the 2nd half of the study and achieved higher success rate compared to posterior flap alone.
  4. In contrast to few other authors, there was considerable difference in success rate when the middle ear mucosa was oedematous, and polypoidal. Success rate was higher if the middle ear was completely dry and healthy as noticed intra-operatively.
  5. Tympanosclerosis did not affect graft success rate, though hearing gain will be less due to restricted ossicular mobility.




 
  References Top

1.
Berthold about myringoplastic, Wein, med B1 1987; 1:1627.  Back to cited text no. 1
    
2.
Ely, ET, Hantbei Chronisher Eiterung des mittelohres. Z.Ohren heilkd, 1881; 10: 154.  Back to cited text no. 2
    
3.
Tangemann, W. Ersatz des Tromel feldes dureh Haultransplantalionen Z. Ohren Weilkd, 13 1833; 13: 174.  Back to cited text no. 3
    
4.
Wullsterin, HC., Zollner F. Panel on Myringoplasty method. Arch Otolaryngol 1963;78:296-304.  Back to cited text no. 4
    
5.
Storss LA: Myringoplasty with use of fascia grafts; Arch Oto-laryngol 1961 49:74:45.  Back to cited text no. 5
    
6.
Shea; J J, Homsy CA; The use of proplast in otologic surgery. Laryngscope 1974;84;1835  Back to cited text no. 6
    
7.
Glasscock ME, Tympanic membrane grafting overlay vs under surface technique Laryngoscope 1973;88;754-770.  Back to cited text no. 7
    
8.
Booth J.B Tympanic reconstruction;5 year report on Tympanoplasty .J Laryngol Otol 1976;89;713-141.  Back to cited text no. 8
    
9.
Puhakka H, Virolainers E, and Rahko T. Long term results of myringoplasty with temporalis fascia. J Laryngol Otol 1979; 93; 1081-1086.  Back to cited text no. 9
    
10.
Sade J, Berco E, Brown M et al. Myringoplasty, short and long term results in a training programmme. J Laryngol Otol 1981;95:653-665.  Back to cited text no. 10
    
11.
Packer P, Mackendrick A, Solar M. What is best in Myringoplasty; underlay or overlay, dura or fascia ? . J Laryngol Otol 1982; 96:25-4.  Back to cited text no. 11
    
12.
Gibb, Alan G. and Channg, Sing-Kiat.. Myringoplasty, a review of 365 operations. J Laryngol Otol 1982; 96,915-930.  Back to cited text no. 12
    
13.
Hordijk,Gerrit J. and Rietema,Sietze J. Tympanic membrane grafting with fascia, perichondrium and vein. J Laryngol Otol 1982; 96:43-47.  Back to cited text no. 13
    
14.
Cable H.R. Surface tension and temporalis fascia grafts. J Laryngol Otol. 1981; 95: 667-673.  Back to cited text no. 14
    
15.
Primrose, W. J, Kerr A. G. The anterior perforation. Clin Otolarngol 1986; 11: 175- 76.  Back to cited text no. 15
    
16.
Sharp JF, Terzis TF, Robinson J. Myringoplasty for anterior perforation; experience with the Kerr flap. J Laryngol Otol 1992; 106:14-16.  Back to cited text no. 16
    
17.
Shih Lucy, de Tars Thomas, Crabtree, James A. Myringoplasty in children. Otolaryngol Head Neck Surg 1991- 105- 74-77.  Back to cited text no. 17
    
18.
Kessler, Alexander, Potsic, William P., James A. myringoplasty in children. Arch Otolaryngol Head Neck Surg 1994; 482-490.  Back to cited text no. 18
    
19.
Attallah MS; Tympanoplasty in children. Otolaryngol Pol 1994;48:441-444.  Back to cited text no. 19
    
20.
Black J.H; Hickey-Sa, Wormald P.J. Ananalysis of the results of myringoplasty in children. Int J Paed Otorhinolary-ngol 1995;31:95-100.  Back to cited text no. 20
    
21.
Gimmemz F, Marco Algarra J. The prognostic value of mucociliary clearance in predicting success in tympanoplasty. J Laryngol Otol 1993; 107: 895-897.  Back to cited text no. 21
    
22.
Laetji, Charles M, Prevention of Sinus tympani retraction following tympanoplasty. Arch Otolaryngol Head Neck Surg 1994; 20: 1395-1396.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Introduction
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